In this episode, I’ll discuss a randomized controlled trial about delayed sequence intubation.
In a typical rapid sequence intubation, there is a period of time referred to as “pre-oxygenation” where the patient needs to breath 100% oxygen for 3 minutes in order to extend the safe apnea time and maximize the chance of successful intubation without hypoxic injury. While this process goes smoothly if the patient can cooperate, that is not always the case. When a patient who requires intubation also has delirium or agitation they often cannot comply with or tolerate the pre-oxygenation process.
While many providers will simply proceed to rapid sequence intubation without adequate preoxygenation, the technique of delayed sequence intubation has been promoted as an alternative.
Delayed sequence intubation is essentially treating the preoxygenation period as a procedure that requires sedation for the patient to tolerate. This is usually accomplished by giving dissociative sedation with ketamine so the patient can receive preoxygenation followed immediately by the rest of a typical rapid sequence intubation process.
Proponents of this technique advocate that the pre-oxygenation step is essential for good patient outcomes while critics argue that the establishment of a definitive airway in a patient with impending respiratory failure should not be delayed even if it means skipping pre-oxygenation.
While previous data and arguments for and against this technique have been limited to retrospective or observational studies, a randomized controlled trial of delayed sequence intubation in trauma patients was recently published in the journal of Anesthesia and Analgesia.
200 critically ill trauma patients that required definitive airway placement were randomized to either delayed sequence intubation (DSI) or rapid sequence intubation (RSI). The DSI group was given a dissociative dose of ketamine followed by 3 minutes of preoxygenation, then paralysis using IV succinylcholine for intubation. The RSI group received the 3 minutes of pre-oxygenation followed by ketamine and succinylcholine for induction and paralysis.
The primary outcome was peri-intubation hypoxia which occurred in only 8% of patients in the DSI group compared to 35% of patients in the RSI group. This difference was statistically significant. The DSI group also had significantly better first-attempt success rates at 83% vs 69%. No patients had hemodynamic instability and there was no difference in adverse events between groups.
This randomized controlled trial provides excellent evidence to support delayed sequence intubation as a technique to provide adequate pre-oxygenation to patients that require a definitive airway but are agitated, delirious, or otherwise unable to comply with pre-oxygentation.
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